Sinusitis

Background

Rhinosinusitis - Inflammation of the lining of the paranasal sinuses

1. Acute (< 4 weeks)
   1. Acute viral
   2. Acute bacterial (0.5-2% of cases)
2. Subacute (4-12 weeks)
3. Chronic (>12 weeks)
4. Other causes
   1. Fungal infections
   2. Allergies

Diagonsis

Classic History & Physical
Feature	Viral	Bacterial
Duration (symptoms)	<10days	Usually >10 days OR worsening symptoms within 10 days after initial improvement
Color change (nasal discharge)	+/−	+++, quality usually yellow-green and thick
Maxillary dental pain		+++, often unilateral and associated with a particular sinus
Postnasal drip		More common
Fever, cough, fatigue		More common
Hyposmia/anosmia		More common

Basic Management

< 10 days symptomatic treatment b/c most likely viral

• Analgesia
• Mechanical irrigation with buffered, hypertonic saline
• Topical glucocorticoids
• Topical decongestants (e.g., oxymetazoline for no more than three days)
• Antihistamines
• Mucolytics

> 10 days or if pt gets better and then worse again (“double sickening”)

• Mild bacterial sinusitis when pain is mild and temperature < 38.3˚C
• Another seven days of observation
• Severe bacterial sinusitis when pain is moderate-severe or temperature ≥38.3˚C
• Consider antibiotics
• If the patient is immunocompromised, has an underlying or complicating condition, or patient fails observation, antibiotics are indicated

Antibiotics

• Choice of antibiotic depends on recent antibiotic therapy (past 4-6 weeks).
• Amoxicillin (500mg PO TID for 10 days)
• TMP-SMX
• Erythromycin
• Azithromycin
• Cefpodoxime

* Cefdinir * Cefuroxime 

• If initial antibiotic failure occurs consider further workup (e.g. CT) and/or further tx with either amoxicillin-clavulanate or respiratory fluoroquinolone
• Nosocomial acute bacterial rhinosinusitis can occur (e.g., after prolonged nasotracheal intubation) and often is associated with gram-negatives; remove foreign bodies and use culture-directed antibiotic therapy

• Immunocompromised patients at risk for acute fulminant fungal rhinosinusitis

Source

DeBonis, Kaji, UpToDate "Rhinosinusitis"